Pharmacotherapeutic strategies for hepatitis B and hepatitis C coinfection

ABSTRACT

Introduction

Hepatitis B (HBV) and Hepatitis C (HCV) infection place a significant burden on the global health system, with chronic carriage leading to cirrhosis and hepatocellular carcinoma. HBV/HCV coinfection can be seen in highly endemic areas and present a heterogenous group given varying virologic profiles. Coinfected patients have a greater risk of advanced liver disease; hence, diagnosis and early antiviral therapy (AVT) should be a priority. Optimal treatment regimens for coinfected patients remain unknown with differing recommendations, particularly relating to the risk of HBV reactivation whilst on AVT for HCV.

Areas covered

This article summarizes the available data on HBV/HCV coinfection with regards to epidemiology, virologic interactions, and risk of HBV reactivation. The authors also provide a framework for the assessment and treatment of coinfected patients.

Expert opinion

There is a moderate risk of HBV reactivation in hepatitis B surface antigen (HBsAg) positive patients undergoing HCV direct-acting antiviral (DAA) treatment; however, clinically significant events are rare. The risk of HBV reactivation in HBsAg negative patients undergoing HCV DAA treatment is negligible. Thus, prophylactic HBV treatment in both groups is not required. The authors recommend close monitoring with HBV treatment if there is evidence of HBV reactivation or elevated alanine aminotransferase levels.

KEYWORDS:

• Coinfection
• direct-acting antivirals
• hepatitis B
• hepatitis C
• reactivation

Article highlights

• HBV/HCV coinfection can be seen due to shared modes of transmission, although the exact worldwide prevalence remains unknown. Coinfection is associated with an increased risk of cirrhosis and hepatocellular carcinoma.

• The molecular and virologic interactions in HBV/HCV coinfection are complex and incompletely understood. Four virologic profiles have been characterised in HBV/HCV coinfection: codominant, HBV dominant, HCV dominant (with occult or overt HBV) or neither replicative.

• Both HBV and HCV have highly effective treatment options aimed at viral suppression for HBV and eradication for HCV. The main issue in treatment of coinfected individuals relates to the risk of HBV reactivation during HCV treatment

• Coinfected patients who are HBsAg positive have a moderate risk of HBV reactivation during DAA treatment for HCV, however, clinically significant events are rare. Hence a close monitoring approach is favoured over pre-emptive therapy.

• Coinfected patients who are HBsAg negative/anti-HBc positive have a negligible risk of HBV reactivation during DAA treatment for HCV.

This box summarizes key points contained in the article.

Declaration of interest

M Danta has received speaker fees and travel support from Gilead Sciences, AbbVie and Merck and Co. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.